FreeCovidTesting.org Questionnaire 

In order to register for the COVID-19 Antibody test, we'll need to ask you a series of questions. Make sure to have a valid form of id (driver's license or government id) and your insurance card (if applicable) on hand for this registration. 

If you have any questions please call us at 888-501-2707

BEFORE YOU START, IF YOU ARE EXPERIENCING ANY OF THESE SYMPTOMS, STOP AND CALL 911:
- Constant chest pain or pressure
- Extreme difficulty breathing
- Severe, constant dizziness or light-headedness
- Slurred speech
- Difficulty waking up

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* 1. First name:

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* 2. Last name:

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* 3. What is your gender?

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* 4. Date of birth (MM/DD/YYYY):

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* 5. Email address:

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* 6. What is the address where you currently live?

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* 7. What is your cell phone number? 

 
 14% of survey complete.

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